Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Last updated: May 17, 2016

CMS Measure ID: CMS138v4
Version: 4
NQF Number: 0028
Measure Description:

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

Initial Patient Population:

All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period

Denominator Statement:

Equals Initial Population

Denominator Exclusions:

None

Numerator Statement:

Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason)

Measure Steward: American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
National Quality Strategy Domain: Community, Population and Public Health
Next Version: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Previous Version: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Measure Score: Proportion
Improvement Notation:

Higher score indicates better quality

Guidance:

If a patient uses any type of tobacco (ie, smokes or uses smokeless tobacco), the expectation is that they should receive tobacco cessation intervention: either counseling and/or pharmacotherapy.

If tobacco use status of a patient is unknown, the patient does not meet the screening component required to be counted in the numerator and should be considered a measure failure. Instances where tobacco use status of unknown is recorded include: 1) the patient was not screened; or 2) the patient was screened and the patient (or caregiver) was unable to provide a definitive answer. If the patient does not meet the screening component of the numerator but has an allowable medical exception, then the patient should be removed from the denominator of the measure and reported as a valid exception.

Exceptions only apply to the screening data element of the measure; once a patient has been screened, there are no allowable exceptions for not providing the intervention.

Specifications

Release Notes

Header

  • Copyright updated.
  • Definition updated.
  • Disclaimer updated.
  • eMeasure version number incremented.
  • Guidance updated.
  • Numerator statement updated.

Logic

  • Added timing constraint to each logic clause in numerator.
  • Health and Behavioral Assessment, Reassessment data element added to measure.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Replaced 'Measurement Start Date' and 'Measurement End Date' with 'Measurement Period' and as necessary, replaced existing timing operator (e.g., replacing 'starts before start of' with 'starts before end of').
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism to specify that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • Replaced 'starts before or during' (SBOD) with 'starts before end of' (SBE).
  • Speech and Hearing Evaluation data element added to measure.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.
  • Updated exception logic to designate ‘Limited Life Expectancy’ as a reason for not performing the ‘Risk Category Assessment: Tobacco Use Screening’.

Value Sets

  • Value set Health and Behavioral Assessment, Reassessment (OID 2.16.840.1.113883.3.526.3.1529): Added value set to measure.
  • Value set Speech and Hearing Evaluation (OID 2.16.840.1.113883.3.526.3.1530): Added value set to measure.
  • Value set Tobacco Use Screening (OID 2.16.840.1.113883.3.526.3.1278): Deleted 1 LOINC code (11366-2), added 2 LOINC codes (72166-2, 39240-7).

External Resources